Team-based digital communication reduced patient-initiated phone calls to the hospital and improved patient satisfaction after orthopedic surgery: a randomized controlled trial in 70 patients

Background and purpose Post-discharge inquiries to the hospital are predominantly conducted through phone calls. The rigid timing of these calls is inconvenient for patients and disrupts the workflows of healthcare professionals. The aim of this study was to investigate the effect of a team-based digital communication intervention (eDialogue) facilitated through a messenger-like commercial solution on patient-initiated phone calls to the hospital after discharge. Secondarily, we investigated other patient-initiated contacts, patients’ perception of continuity of care, and their perception of feeling safe and satisfied after hospital discharge. Methods On the day of discharge, 70 surgically treated orthopedic patients were randomized to the intervention group with access to eDialogue (n = 35) or the control group with standard communication pathways by phone call (n = 35) for the following 8 weeks. Through eDialogue, the intervention group had access to team-based asynchronous digital communication in text and photos with healthcare professionals across disciplines and sectors. Inclusion criteria were discharge to own home and receipt of rehabilitation services from both hospital and primary care after discharge. Results We found a significant reduction in the mean number of patient-initiated phone calls to the hospital from 2.3 (95% confidence interval [CI] 1.4–4.1) in the control group to 0.5 (CI 0.3–1.0) in the intervention group (P = 0.004). Across groups, patients reported similar perceptions of continuity of care; however, the participants in the intervention group expressed significantly improved perceptions of, and satisfaction with, access to healthcare after discharge. Conclusion Access to eDialogue reduced patient-initiated phone calls to the hospital, enhanced patient satisfaction with healthcare accessibility, and did not compromise patients’ perception of continuity of care after discharge compared with standard communication pathways.


Secondary outcomes
Secondary outcomes included other contacts made by participants after discharge, patients' perception of continuity of care, and patients' perception of feeling safe and satisfied with access to healthcare after discharge.In an exploratory analysis, we assessed the use of eDialogue by the intervention group as well as participants' future preferences regarding communication modalities and ratings of access to eDialogue.

Contacts to the hospital other than by phone call and contacts to other healthcare facilities
From the questionnaire used for the primary outcome (Screenshot 1-3), knowledge on participants' contacts to the hospital made by other modalities was be collected, such as email, SMS and video consultation.Moreover, contacts made to other healthcare facilities outside the hospital, such as general practitioner, district nursing, municipal physiotherapy or other places, would be collected.This was reported as a secondary outcome, to fully grasp patient-initiated contacts throughout the healthcare system.

Patients' perception of continuity of care
The Patient Continuity of Care Questionnaire (PCCQ), developed by Hadjistavropoulos et al. (2008) [2], and based on the dimensions of Continuity of Care (COC) defined by Haggerty et al. [3], was used to assess patient's perception of continuity of care in this study.The concept of COC is used as a measure for quality of care in transitions.It encompasses informational continuity, which is the use of medical or personal information to provide appropriate care over time, management continuity, which refers to the provision of timely, coordinated and complementary services that are responsive to patients needs to connect care over time, and relational continuity which involves the consistency and quality of relationships between patients and providers as a means to connect care over time.All three dimensions should be achieved to ensure COC.
The original version of PCCQ was developed and psychometrically evaluated in Canada [2].It was based upon the Heart Continuity of Care Questionnaire, adapted and tested in a geriatric and orthopedic surgery patient population.It has since then been translated and validated in other countries for different patient populations, such as patients with heart disease [4].Answers to each question is given on a 5-point Likert scale ranging from "strongly disagree" (1 point) to "strongly agree" (5 points).Patients can also report 'not applicable' (N/A) if they do not find the questions relevant to their situation.The total score is calculated, and higher scores represent a higher degree of perception of continuity of care.The questionnaire is divided in two sections, where one involves questions regarding "before discharge" and the latter includes questions regarding "after discharge".These sections can be summarized separately.Moreover, the PCCQ can be divided into 6 subcategories, each targeting specific dimensions of COC before and after discharge (management, informational and relational COC).
Prior to this study, we translated and culturally adapted the PCCQ into Danish inspired by the principles of good practice described by Wild et al. (ISPOR) [5] and in collaboration with the developer of the questionnaire.Additional information on the translation process can be obtained upon request to the first author.A manuscript is currently being prepared for publication.An example of the translated version of the questionnaire is shown in Screenshot 4.An integral part of the translations process involved cognitive debriefing with 10 orthopedic surgery patients comparable to patients included in this study.However, we did not test the psychometric properties of the translated version.Also, for this study the PCCQ was applied differently than originally intended.The section "before discharge" was distributed to participants on the day of discharge to provide a baseline measure that could detect differences in patients' perception prior to randomization (Screenshot 4 shows an example of one question from the "before discharge" section).
We were careful about collecting data for the "before discharge" section at the day of discharge after participants had received discharge information from hospital staff and right before leaving the hospital.The section "after discharge" was then collected four weeks after randomization and discharge (Screenshot 5 displays an example of one question from the "after discharge" section).Screenshot 4.

Screenshot 5.
LWH Jensen et al.Team-based digital communication reduced patient-initiated phone calls to the hospital after orthopedic surgery and improved patient satisfaction: a randomized controlled trial in 70 patients

Patients' perception of feeling safe and satisfied after discharge
A simple 4-item questionnaire was developed by the research team prior to the study to address patients' perception of feeling safe and satisfied with access to healthcare after hospital discharge.The questions concerned the extent to which 1) patients had been feeling safe after discharge, 2) had knowledge of whom to contact if needed, 3) experienced ease of access to healthcare, and 4) were satisfied with opportunities for contact after discharge.The questionnaire was tested for wording and understanding in 12 orthopedic surgery patients by qualitative interviewing [1].Screenshot 6 shows the 4-item questionnaire in Danish.

Primary outcome data
The complete distribution of phone calls per group presented by a density plot (Figure 1).
The mean number of phone calls per week by groups shows that the majority of phone calls were made within the first 2 weeks after hospital discharge (Figure 2).

Screenshot 6 .
LWH Jensen et al.Team-based digital communication reduced patient-initiated phone calls to the hospital after orthopedic surgery and improved patient satisfaction: a randomized controlled trial in 70 patients Patients' preferences for post discharge communication (only intervention group) Eight weeks after discharge, participants in the intervention group were also asked to state what kind of contact modality they would prefer for post-discharge inquiries, choosing between eDialogue, phone call, email or video consultation (Screenshot 7), and 2), and to rate to which extent they felt eDialogue had supported them after discharge and to what extent their access to eDialogue had made the post-discharge period easier for them (Screenshot 8).Screenshot 7. Preferences regarding contact modality by intervention group Screenshot 8. Rating of eDialogue by intervention group LWH Jensen et al.Team-based digital communication reduced patient-initiated phone calls to the hospital after orthopedic surgery and improved patient satisfaction: a randomized controlled trial in 70 patients

Figure 2 .
Figure 2. The mean number of phone calls per week by groups LWH Jensen et al.Team-based digital communication reduced patient-initiated phone calls to the hospital after orthopedic surgery and improved patient satisfaction: a randomized controlled trial in 70 patients